Surgical site infection Implementing NICE guidance ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on surgical site infection. This guideline has been written for all healthcare professionals who are involved in the care of patients before, during and after surgery, including GPs, surgeons, nurses, tissue viability specialists and other staff who care for patients who are at risk of, or have, surgical site infections. The guideline is available in a number of formats. You can download these from the NICE website or order printed copies of the quick reference guide by calling NICE publications on 0845 003 7783 or sending an email to publications@nice.org.uk. Quote reference number N1701. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters to help highlight key points to raise in your presentation and to provide supplementary information to the slides. Where necessary, the recommendation will be given in full. Please feel free to adapt, amend or remove these as you see necessary. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. 2008 NICE clinical guideline 74

Updated guidance This guideline updates and replaces ‘Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds’ (NICE technology appraisal guidance 24 [published April 2001]).

What this presentation covers Background Scope Key priorities for implementation Costs and savings Discussion Find out more NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then present the key priorities for implementation. The NICE guideline contains four key priorities for implementation, which you can find in your quick reference guide. Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Finally, we will end the presentation with further information about the support provided by NICE.

Background Surgical site infections (SSI): Are largely preventable Can have a significant effect on quality of life for the patient Result in a considerable financial burden to healthcare providers Compose up to 20% of all healthcare-associated infections Develop in at least 5% of patients having surgery NOTES FOR PRESENTERS: Key points to raise: Surgical site infection (SSI) is where a wound infection occurs related to the site of an invasive (surgical) procedure Measures can be taken in the pre-, intra- and postoperative phases of care to reduce risk of infection. It is important that healthcare professionals adhere to best practice to prevent and manage SSI. SSI is associated with considerable morbidity and extended hospital stay. Advances in surgery and anaesthesia have resulted in patients who are at greater risk of SSI being considered for surgery. Additional information: In the UK, SSI has been found to more than double the length of postoperative stay in hospital, this alone increasing the costs of care by between £814 and £6626 depending on the type of surgery and the severity of the infection. The indirect costs, due to loss of productivity, patient dissatisfaction and litigation, and reduced quality of life have been studied less extensively. It is an important cause of morbidity and mortality for patients having surgery and significantly increases costs of treatment. The Third National Prevalence Survey of Infections in Hospitals (2006) reported an overall prevalence of healthcare-associated infection of 8.2%. 13.8% of this was attributable to SSI. Surveillance of SSI in English hospitals between 1997 and 2001 reported an incidence of 4.2% from the 152 hospitals that participated. However, definitions and variation in postdischarge surveillance are critical to the accuracy of these figures. Patient-related factors and operation characteristics influence the risk of SSI development. The assessment and identification of the presence of these factors facilitates both surveillance and the implementation of targeted prevention measures. In addition, the incidence of infected surgical wounds may be influenced by factors such as preoperative care, the operating room environment, postoperative care, type of surgery, and care in the community. Treatment of SSI should be directed by patient factors, operation characteristics, empirical signs and symptoms and local microbiological surveillance.

Scope The guideline covers all patients, both adults and children, having surgical incisions through the skin The guideline covers both acute hospital trusts and primary healthcare settings NOTES FOR PRESENTERS: Key points to raise: This includes minimally invasive surgery (arthroscopic, thoracoscopic and laparoscopic surgery). Incisional infections up to 30 days post initial procedure are covered. The guideline does not cover patients having a surgical procedure that does not involve a visible surgical incision, and therefore does not result in a conventional surgical wound. In addition, procedures involving intravascular catheters, shunts, endoscopy and pin sites are not covered.

Key priorities for implementation Information for patients and carers Preoperative phase Intraoperative phase Postoperative phase NOTES FOR PRESENTERS: The NICE guideline contains many recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into 4 areas of key priority and within these there are 13 recommendations that we will consider in turn.

Information for patients and carers Offer patients and carers clear, consistent information and advice throughout all stages of their care NOTES FOR PRESENTERS: Recommendation in full: Information and advice for patients and carers should include – the risks of surgical site infections – what is being done to reduce risks – how to care for the wound after the patient is discharged – how to recognise a surgical site infection – who to contact if they are concerned about possible surgical site infection – how surgical site infections are managed. Additional Information: The Health Protection Agency is producing a leaflet for patients on surgical site infection. Please see their website (http://www.hpa.org.uk) and search for surgical site infection – general information, where there is a link to their leaflet.

Preoperative phase (hair removal) Do not use hair removal routinely Do not use razors for hair removal, because they increase the risk of surgical site infection If hair has to be removed, use electric clippers with a single-use head on the day of surgery NOTES FOR PRESENTERS: Key points to raise: There is no evidence that hair removal in general influences the incidence of SSI, but it might be appropriate in some clinical circumstances. Evidence showed that the use of electric clippers for preoperative hair removal was cost effective when compared with no hair removal, shaving using razors and depilatory cream. The use of electric clippers was not only found to generate more quality-adjusted life years but was also found to be less expensive (page 27 of full NICE guideline). Recommendations in full: Do not use hair removal routinely to reduce the risk of surgical site infection. (1.2.2) If hair has to be removed, use electric clippers with a single-use head on the day of surgery. Do not use razors for hair removal, because they increase the risk of surgical site infection. (1.2.3)

Preoperative phase (antibiotic prophylaxis) Give antibiotic prophylaxis to patients before; clean surgery involving the placement of a prosthesis or implant, clean-contaminated surgery and contaminated surgery Do not use prophylaxis routinely for clean non-prosthetic uncomplicated surgery Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis Consider giving prophylaxis on starting anaesthesia, or earlier for operations using a tourniquet NOTES FOR PRESENTERS: Key points to raise: Do not use the following routinely to reduce the risk of surgical site infections: Nasal decontamination with topical antimicrobial agents targeting Staphylococcus aureus Mechanical bowel preparation Recommendations in full: As on slide (1.2.11) As on slide (1.2.12) Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis. (1.2.13) Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used. (1.2.14) Additional Information: Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation. (1.2.17) Definitions: Clean: an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary or genitourinary tracts are not entered. Clean-contaminated: an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered. Contaminated: an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category.

Intraoperative phase Prepare the skin immediately before incision using an antiseptic preparation - povidone‑iodine or chlorhexidine are most suitable Cover surgical incisions with an appropriate interactive dressing at the end of the operation NOTES FOR PRESENTERS: Key points to raise: Do not use the following to reduce the risk of surgical site infections: non-iodophor-impregnated incise drapes. If an incise drape is required, use an iodophor-impregnated drape unless the patient has an iodine allergy insulin routinely to optimise postoperative blood glucose levels in patients who do not have diabetes diathermy for surgical incision wound irrigation intracavity lavage intraoperative skin redisinfection or topical cefotaxime in abdominal surgery. Recommendations in full: Prepare the skin at the surgical site immediately before incision using an (aqueous or alcohol-based) antiseptic preparation: povidone‑iodine or chlorhexidine are most suitable. (1.3.7) As on slide. (1.3.17) Additional information: Definition: Interactive dressing: Modern (post-1980) dressing materials. Designed to promote the wound healing process through the creation and maintenance of a local, warm, moist environment underneath the chosen dressing, when left in place for a period indicated through a continuous assessment process.

Postoperative phase Refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate dressings for the management of surgical wounds that are healing by secondary intention NOTES FOR PRESENTERS: Key points to raise: Do not use the following to reduce the risk of surgical site infections: topical antimicrobial agents for surgical wounds that are healing by primary intention Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions for surgical wounds that are healing by secondary intention. Recommendation in full: As on slide. (1.4.8) Definition: Healing by secondary intention: Occurs when a wound is deliberately left open at the end of an operation because of excessive bacterial contamination, particularly by anaerobes or when there is a risk of devitalised tissue, which leads to infection and delayed healing. It may be sutured within a few days (delayed primary closure), or much later when the wound is clean and granulating (secondary closure), or left to complete healing naturally without the intervention of suturing.

Costs and savings The guideline on surgical site infection is unlikely to have a significant national resource impact in the NHS Recommendations that may have local resource impact are: Information for patients Hair removal Wound dressings Optimising blood glucose levels Maintaining patient homeostasis NOTES FOR PRESENTERS: NICE has worked closely with the guideline developers and other people in the NHS to look at the major costs and savings related to implementing this guideline and found that the guideline is unlikely to result in any significant changes based on national assumptions. However, different areas may vary from the national average and it is important to scrutinise the recommendations likely to have the most significant resource impact locally to make sure that practice matches the national average. For further information please refer to the costing statement for this guideline, which can be found on the NICE website.

For discussion What information about surgical site infection is given to patients and carers? When and how is it given? What structures and processes are there in place to ensure best practice in the care of surgical wounds (e.g. Wound management formulary)? How accessible is a tissue viability nurse (or similar) for advice on dressings? NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. Additional questions: How could the trust’s approach to the prevention of surgical site infection be more comprehensive? How do you ensure that the information about SSI provided to patients is consistent across clinics? How do you ensure consistency with the NICE guidelines? What is the organisation’s current arrangements for hair removal? What change is indicated in light of the guideline? How do you ensure that patients are always informed when they have received antibiotic prophylaxis during surgery?

Find out more Visit www.nice.org.uk/CG74 for: Other guideline formats A costing statement Audit support NOTES FOR PRESENTERS: The guideline is available in a number of formats. The quick reference guide – which summarises the guidance The NICE guideline – which includes all of the recommendations in full. The full guideline – which includes all of the evidence and rationale. ‘Understanding NICE guidance’ – a version for patients and carers You can download these from the NICE website or order printed copies of the quick reference guide and ‘Understanding NICE guidance’ by calling NICE publications on 0845 003 7783 or by sending an email to publications@nice.org.uk. Quote reference number N1701 for the quick reference guide and N1702 for ‘Understanding NICE guidance’. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing statement – a costing statement gives the background to the national savings and costs associated with implementation. Audit support – assists NHS trusts to determine how well they meet NICE recommendations.